Mary’s insurance denied her the coverage she needed to keep seeking treatment and surgeries for the genetic illness that she was diagnosed with when she was born. Von Hipple Landau (VHL) is a type of cancer that causes malignant tumors to form in multiple organs of the body which initiated her permanent blindness in 2007. She also experiences numbness, weaknesses and loss of balance throughout her body. She cannot eat with her hands as they are asleep at her sides. Constant treatment including scans and MRIs are necessary to keep up with her changing body. After 10 years of receiving insurance coverage at MD Anderson, her provider refused to pay for the rest of her treatment.
MD Anderson is one of the most respected cancer treating facilities in the United States. As a Medicaid recipient, Mary was informed MD Anderson was no longer in network with her provider, United Health Care. United Health Care suggested she request out-of-network treatment stating it was medically necessary. Mary was able to continue to receive treatment until 2018. In the same year, United Health Care denied her request for out-of-network treatment.
United Health Care suggested an in-network provider that could see her and assist with her treatments. However, the in-network doctor had limited knowledge on her illness and even failed to diagnose her with a pancreatic tumor. Mary was skeptical of his diagnoses as her long-time treating physician told her that he was surprised the in-network doctor didn’t detect any tumor, as the one he diagnosed her with had actually increased in size since he last examined her.
Mary exhausted all of her appeals through United Health Care and was referred directly to Texas HHSC. She then appealed directly to Texas HHSC. Texas HHSC held a hearing where Mary and her treating physician were able to testify regarding the medical necessity of treatment at MD Anderson. The treating physician testified that the in-network provider did not specialize in her form of cancer and failed recognize she had a pancreatic tumor. Texas HHSC upheld United Health Care’s denial for out-of-network treatment.
Mary turned to Lone Star Legal Aid for assistance. Her attorney, Channing Guidry, filed an Administrative Review of the Texas HHSC decision within 30 days, as required by their policy. With her attorney and enough supporting documents, Texas HHSC reversed its decision to uphold United Health Care’s denial of out-of-network treatment. As a result, United Health Care is ordered to cover Mary’s treatment at MD Anderson.
“Lone Star Legal Aid has given me confidence and made me a stronger person. Working with them taught me to not let negativity stop me from getting what I deserve.” Mary said. “Don’t let obstacles slow you down.”
- Name changed to protect the client’s identity.